Basic Information
| Provider Information | |||||||||
| NPI: | 1023037611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GURVITZ | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | Z | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | BOSTON CHILDREN'S HOSPITAL / CARDIOLOGY | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556508 | ||||||||
| FaxNumber: | 6177398632 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | BOSTON CHILDREN'S HOSPITAL / CARDIOLOGY | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556508 | ||||||||
| FaxNumber: | 6177398632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | A61361 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208000000X | MD00045538 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | MD00045538 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 245758 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 207RA0002X | 245758 | MA | Y |
ID Information
| ID | Type | State | Issuer | Description | 8436511 | 05 | WA | MEDICAID | 00A613610 | 01 | CA | MEDICAL PPIN # | OTHER |